Behavioral symptoms associated with dementia and inappropriate psychotropic medication use in U.S nursing homes

Abstract

Background: Behavioral symptoms associated with dementia often occur concurrently. Psychotropic medications are used to treat behavioral symptoms in nursing homes (NHs) despite limited efficacy and the risk of adverse effects. Psychotropics are considered an easier solution for behavioral symptoms with fewer nursing staff. Inappropriate psychotropic medication use has been the focus of policy attention due to safety issues. A NH deficiency of care can be cited for inappropriate psychotropics use (F-758 tag). Purpose: The purposes of this dissertation are to examine factors of co-occurring behavioral symptoms of dementia (Aim 1), the occurrence of F-758 tag citations in relation to nurse staffing (Aim 2) and to explore how NH deficiency citations describe inappropriate psychotropics use to manage behaviors (Aim 3). Methods: For aim 1, general linear mixed models were used to explore co-occurring behavior symptoms in relation to cognitive status, physical function and analgesics use among 336 NH older adults diagnosed with dementia. For aim 2, generalized linear mixed models estimated associations between the occurrence of F-758 tags and nurse staffing levels among 13,614 NHs from December 2017 to 2018. Aim 3 used a mixed-method study design that combined descriptive and content analysis of F-758 deficiency reports (n=444 NHs) during January to March 2018. Results: Having multiple behavioral symptoms was negatively associated with better cognitive status and regular analgesics use (p<.001 and p=.009, respectively) (Aim 1). NHs with greater hours per resident day for RNs (OR=0.54, 95% CI=0.44-0.67), certified nurse assistant (OR=0.87, 95% CI=0.77-0.99), total nurse staff (OR= 0.87, 95% CI= 0.79-0.96), and greater RN skill-mix (OR=0.10, 95% CI=0.04-0.26) had significantly lower odds of F-758 tags (Aim 2). Common reasons for inappropriate psychotropic medication use included failure to monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs) and maintain14 day limits on PRN psychotropic medication orders (121 NHs) (Aim 3). Conclusions: Consideration of cognitive function and pain management are important for multiple behavioral symptoms (Aim 1). NHs need to have adequate nurse staffing levels to reduce inappropriate psychotropic medication use (Aim 2). Aim 3 analysis suggests areas for improvement, that could potentially reduce F-758 citations.